HESI HEALTH ASSESSMENT LATEST 2024 TEST
BANK QUESTIONS WITH COMPLETE
SOLUTIONS NIGHTINGALE COLLEGE
. The nurse is assessing the apical pulse of a patient who has had
a normal heart rhythm during the past several assessments. What
should the nurse do when every third heartbeat is now skipped
during the entire minute of apical pulse assessment?
A. Notify the practitioner.
B. Order laboratory testing for cardiac enzyme levels.
C. Document the finding for later review.
D. Perform heart massage. Correct Answer A. Notify the
practitioner.
The skipping of every third heartbeat signifies an arrhythmia,
which may be dangerous and should be reported to the
practitioner as soon as possible. Documenting the finding for
later review could be detrimental to the patient. Ordering
laboratory tests is not within the nurse's scope of practice. Heart
massage is an open chest procedure performed only by
practitioners in a critical situation.
1. A patient is on bed rest following a hip replacement. What is
the nurse assessing for when checking the patient's circulation
and coagulation studies?
A. Increased bleeding tendency
B. Signs of infection
,C. Thrombocytopenia
D. Virchow triad Correct Answer D. Virchow triad
Three elements (commonly referred to as the Virchow triad)
contribute to the development of VTE: hypercoagulability of the
blood, venous wall damage, and stasis of blood flow. Signs of
infection are best assessed by looking at the white blood cell
count and differential, as well as by looking at vital signs and
the clinical picture. Increased bleeding tendencies may be
recognized in the coagulation studies, but the risk for a patient
on bed rest is VTE caused by inactivity and blood stasis.
Thrombocytopenia is indicated by a low platelet count and
signifies a possible risk for bleeding.
2. The nurse is preparing to teach the patient diaphragmatic
breathing. Which position should the nurse assist the patient
into?
A. Side-lying position
B. Supine position
C. High-Fowler position
D. Trendelenburg position Correct Answer C. High-Fowler
position
The patient should maintain an upright (high-Fowler) position
when practicing controlled coughing to facilitate diaphragm
excursion and enhance thorax and abdominal expansion. Supine,
side-lying, and Trendelenburg positions are not recommended
for controlled coughing because these positions do not facilitate
diaphragm excursion and do not enhance thorax and abdominal
expansion.
,4. Which action is appropriate before a nurse implements a
comfort promotion strategy, such as deep breathing, for the first
time?
A. Administer an analgesic.
B. Ensure that the patient has not received an analgesic for at
least 2 hours.
C. Explain to the patient that many times comfort-promotion
strategies are ineffective.
D. Stop patient-controlled analgesia. Correct Answer A.
Administer an analgesic.
Before implementing deep breathing for the first time, the nurse
may administer an analgesic so the patient can gain the level of
comfort needed to perform the technique effectively. The nurse
should explain that comfort-promotion strategies can be an
effective addition to pain control. Patient-controlled analgesia
may be used with deep breathing.
4. Which statement is true regarding body temperature for an
older adult patient?
A. Older adults are normally at the upper end of the normal
temperature range for adults.
B. The normal physiologic changes associated with the aging
process may result in a higher body temperature for an older
adult.
C. Older adults are not sensitive to environmental temperature
changes because their thermoregulatory systems are efficient.
, D. Temperatures considered within the normal range often
reflect a fever in an older adult. Correct Answer D.
Temperatures considered within the normal range often reflect a
fever in an older adult.
The normal physiologic changes associated with the aging
process may result in a lower body temperature, which coupled
with less temperature variability may result in a blunted fever
response. Therefore, temperatures considered within the normal
range often reflect a fever in an older adult. A normal
temperature for an older adult is at the lower end of the
acceptable temperature ranges for adults. Older adults are
sensitive to environmental temperature changes because their
thermoregulatory systems are not as efficient.
5. What should the nurse do before providing a neck massage to
a patient?
A. Stop the patient-controlled analgesia pump.
B. Have the patient sit up in the Fowler position.
C. Administer a sedative to help the patient sleep.
D. Determine that the patient has no neck injury. Correct
Answer D. Determine that the patient has no neck injury.
The nurse must ensure that the patient has no neck injury or
condition that contraindicates neck manipulation before
beginning a neck massage. The patient should be in the prone
position during a neck massage, not the Fowler position. A
sedative is not required before a neck massage. A neck message
works in conjunction with PCA to decrease the patient's pain
and in turn decrease the amount of pain medication the patient
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